This form is to authorize, request, give permission for, and consent to psychotherapy services from the practice of Grace McDonald, M.A., Registered Marriage & Family Therapist (RMFT) and Registered Clinical Counsellor (RCC).
I understand that our relationship is strictly voluntary and that I may choose to terminate therapy at any time. I understand that my therapist may choose to terminate therapy if he or she determines that continued therapy with him or her will not be beneficial to me. In such a case, I understand that the therapist will explain the reasons for his or her decision. He or she will offer me appropriate referrals or referral sources to continue therapy if I wish, and aid as is appropriate in the transition.
The frequency and type of treatment will be decided between my therapist and me.
I understand that the purpose of these procedures will be explained to me and be subject to my verbal agreement.
I understand that there is an expectation that I (or the minor, I am authorizing therapy for) will benefit from psychotherapy but there's no guarantee that this will occur.
I understand that the maximum benefit will occur with consistent attendance and that at times, I may feel conflicted about the therapy, as the process can sometimes be uncomfortable.
I understand that the therapy is confidential aside from exceptions to confidentiality as stated in the law. I understand that the therapist is allowed or required to breach confidentiality by contacting appropriate persons and/or by reporting to the appropriate authorities reasonable suspicion if he/she believes that a child, elderly or disabled person is being abused, including by neglect, assault, battery, or sexual molestation; or if there is a threat of serious harm to myself or another person.